The Journal of Tehran University Heart Center
Volume:2 Issue: 3, Jul 2007

Depression is a serious disorder in today’s society, with the estimates of lifetime prevalence being as high as 21% of the general population in some developed countries. As defined by the American Psychiatric Association, depression is a heterogeneous disorder often manifested with symptoms at the psychological, behavioral, and physiological levels. Such patients are often reluctant to take synthetic antidepressants in their appropriate doses due to their anticipated side effects including inability to drive a car, dry mouth, constipation, and sexual dysfunction. As a therapeutic alternative, effective herbal drugs may offer advantages in terms of safety and tolerability, possibly also improving patient compliance. The advent of the first antidepressants, Monoamine Oxidase Inhibitors (MAOIs) and Tricyclic Antidepressants (TCAs), in the 1950s and 1960s represented a dramatic leap forward in the clinical management of depression. The subsequent development of the Selective Serotonin Reuptake Inhibitors (SSRIs) and the Serotonin Norepinephrine Reuptake Inhibitor (SNRI) venlafaxine in the past decade and a half has greatly enhanced the treatment of depression by offering patients medications that are as effective as the older agents but are generally more tolerable and safer in an overdose. The introduction of atypical antidepressants, such as bupropion, nefazadone, and mirtazapine, has added substantially to the available pharmacopoeia for depression. Nonetheless, rates of remission tend to be low and the risk of relapse and recurrence remains high. One of the concerns regarding the safety of antidepressant is its potential risk of cardiotoxicity and cardiovascular side effects. In this review, we will focus on the cardiovascular side effects of different types of antidepressants.

Lipid peroxidation is a free radical-generating process which occurs on every membranous structure of the cell. Free radicals are known to be involved in a number of human pathologies including atherosclerosis. The purpose of this cross-sectional study was to examine the association between pre-hypertension status and oxidative stress markers [total antioxidant capacity (TAC) and malonedialdehyde (MDA) levels] in a random sample of cardiovascular disease-free women. In this study, 160 women of 20-45 years of age were randomly selected. General information data were gathered from each sample using questionnaires and face-to-face interviews. Blood pressure (BP) was measured for each subject. Body weight, height, and waist and hip circumferences were measured and body mass index (BMI)and waist-to-hip ratio (WHR) were calculated for each subject. Venous blood samples were drawn from the subjects, and plasma was separated. In this study, the oxidative stress status was assessed by measuring the concentrations of plasma MDA and TAC levels Our results show that both systolic and diastolic blood pressures were inversely correlated with TAC (p<0.01) and positively correlated with MDA levels (p<0.01). Particularly, compared to the normotensive subjects, the pre-hypertensives had 19% lower TAC (p<0.05) and 22% higher MDA levels (p<0.01), after correcting for multiple comparisons and adjusting for age, body mass index, waist-to-hip ratio, and other potential confounders. Our findings revealed an association between pre-hypertension and oxidative stress markers linked to atherosclerosis process. Thus, the identification of the underlying molecular mechanisms in pre-hypertension, which seem to include oxidative stress, may serve as an important lead for developing potentially new treatment modalities in this group of patients at risk for future cardiovascular complications.

Coronary angiography, albeit a safe procedure, may cause serious complications especially in patients with left main stenosis (LMS). This study was designed to investigate the efficacy of workload achieved by exercise tolerance test (ETT) in predicting LMS in candidates for coronary angiography. A total of 743 patients with a positive ETT who subsequently underwent cardiac catheterization were retrospectively studied. Different risk factors were compared among the patients with and without LMS. A multivariate forward stepwise logistic regression analysis was used to identify the main predictors of LMS. Among our 743 patients, 72% were male and 41(5.5%) had LMS≥50%. Patients with LMS, by comparison with those without LMS, were older and were more likely to be male and had higher percentages of ejection fraction less than 35% (EF≤35%), history of myocardial infarction, and lower metabolic equivalent (METs). After adjusting for important variables, we found that EF≤35%, METs, and the male sex were significant independent predictors of LMS (P<0.0001, P=0.024, and P=0.006, respectively). When the patients were divided into two groups in terms of METs≤7 and METs>7, LMS was found in 8.3% and 3.6%, respectively (P=0.006). The risk of having LMS in the men with METs≤7 was higher than that in those with METs>7 (OR=3, P=0.003, 95% CI=1.50-6.00). Among the patients with LMS, stenosis≥70% was found in 44% in METs≤7 and 18.8% in METs>7. Lower METs correlated with an increased likelihood of significant LMS in the patients, especially if they were male, who had a positive exercise test and were suspected of coronary artery disease. It is, therefore, advisable that patients with METs≤7 receive due attention during coronary angiography.

Percutaneous coronary angioplasty (PTCA) of a coronary stenosis without documented ischemia at noninvasive stress testing is often performed, but its benefit is unproven. Coronary pressure– derived fractional flow reserve (FFR) is an invasive index of stenosis severity defined as the ratio of maximal blood pressure in a stenotic vessel to the normal maximal pressure in the same vessel. FFR is a reliable substitute for noninvasive stress testing and values below 75% identifies stenoses with hemodynamic significance. It is a method that can provide a reliable assessment of coronary stenosis especially in those with intermediate lesions. It can highly impact on decision-making in therapeutic planning and prevent many unnecessary procedures that are routinely done in these cases. In the present study, we report the results of FFR measurements in a series of patients, and this is the first report on the FFR measurement in Iran. The FFR measurement was performed for eleven vessels with intermediate stenosis, and in seven lesions (63.6%) it led to changes in the treatment strategy. On the basis of FFR, percutaneous coronary intervention (PCI) was changed into medical follow-up in five lesions, medical follow-up changed to PCI in one lesion, and coronary artery bypass grafting (CABG) changed to medical follow-up in another.

Serum trace element alteration has been reported in dilated and ischemic cardiomyopathy. The reports were controversial. We have studied serum Zinc level in cardiomyopathy patients in northern province of Mazandaran and compared them with healthy volunteers. Serum Zinc level was measured in 30 ischemic and 18 dilated cardiomyopathy patients against 27 healthy volunteers. It was measured using atomic absorption spectrophotometry. Statistical analysis was performed using SPSS for Windows version 14 and independent t-test was used for comparing serum Zinc level in ischemic and dilated cardiomyopathy. Pearson correlation and ANOVA tests were used for numeric variables in three different groups. P<0.05 was considered as statistically significant. The mean serum Zinc level was 0.97±0.25, 1.05±0.27, 1.21±0.42 mg/L for idiopathic dilated cardiomyopathy, ischemic cardiomyopathy and healthy volunteers respectively. There was no significant difference between three groups. There was also no correlation between echocardiography data and serum Zinc level. This study showed serum Zinc level might not have a role in pathogenesis of ischemic and dilated cardiomyopathy. As intracellular Zinc level play a role in heart subjected to ischemia- reperfusion, measuring intracellular Zinc may give us a better clue about role of Zinc or other trace elements in pathogenesis of cardiomyopathy.

Coronary artery disease (CAD) is emerging as a major public health concern in most developing countries. During the past 10 years, the vast majority of over 100 case-control retrospective studies have shown that elevated plasma homocysteine level is a strong independent risk factor for coronary artery disease. Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme in folate and homocysteine metabolism. A second polymorphism, A1298C, in MTHFR gene, is reported to be associated with decreased enzyme activity and may give rise to elevated blood homocysteine level and increased risk of coronary artery disease. In the present study we used PCR-RFLP analysis to investigate the association between A1298C polymorphism and blood homocysteine level and the risk of CAD in 100 patients compared to 100 normal controls. The frequency of mutated allele and genotype distribution showed no significant difference between patient and control groups. Although the elevated level in blood homocysteine were observed in Iranian CAD cases compared to the normal control, the A1298C polymorphism was not associated with increased CAD risk in studied population as supported by a P value>0.05 and chi-square equal to 0.697. An increased plasma homocysteine concentration confers an independent risk factor for CAD. Although A1298C polymorphism in MTHFR gene has effects on enzyme activity but our findings do not support a major role for this polymorphism in homocysteine metabolism and it can not be considered a major risk factor for coronary artery disease in a selected Iranian population.

Left ventricular dysfunction is one of the most powerful predictors of early and late outcomes in patients who undergo coronary artery bypass grafting (CABG). The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay (LOS) after CABG in patients with an ejection fraction (EF) of 30% or less. Seven hundred seven patients who underwent CABG with EF≤30% in Tehran Heart Center between January 2002 and January 2006 were entered and compared with 9467 patients with EF>30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. The thirty-day mortality rate (2.3% vs. 0.8%, P<0.0001), the mean of LOS (P<0.0001), and the mean of the length of ICU stay (P<0.0001) were higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the mean of NYHA score (P=0.0081), prolonged ventilation (P=0.0051), and renal failure (P=0.0606) were related to the 30-day mortality rate. Also, the prolonged LOS in these patients was correlated with the female gender (P=0.0018) and atrial fibrillation (P=0.0164). Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with left ventricular dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital

This is a case of a modified Blalock-Taussig shunt, which was complicated by perigraft transudative, fibrinous fluid accumulation and recurrence after surgical intervention. Follow-up and expectant management of the patient was successful. Our experience regarding this complication is presented.